Families of victims who suffered abuse at former care homes in Devon have responded with ‘dignity and determination’ in their resolve to ensure similar abusive practice does not happen again.
The Safeguarding Adult Review (SAR) by Devon’s multi-agency Safeguarding Adult Board into the abuse of adults with learning disabilities, autism and mental health problems in homes run by the former Atlas Care, (no longer operating), has now concluded following a lengthy police investigation and legal proceedings.
The court case, between May 2016 and October 2017, saw Directors and employees of the former care company convicted of a range of offences ranging from conspiracy to falsely imprison, false imprisonment of residents, and ill-treatment and neglect. The conviction of Paul Hewitt, Atlas Director, for a health and safety offence, was later quashed by the Court of Appeal with fines and costs set aside.
The court proceedings revealed that Atlas residents, many of whom were placed by authorities outside Devon, were subjected to systemic neglect; seclusion in rooms without food, drinks, heating or access to toilets; physical assaults; and orders from staff to undertake housework and gardening tasks, which were ‘tests’ to establish their compliance.
The Police investigation, 2011 to 2017, focused on the experience of 10 adults over a two year period who were residents of three Atlas care homes in Devon. It identified 2,600 incidents of seclusion with some residents falsely imprisoned up to 400 times.
Six families, of the 34 residents placed in Atlas homes in Devon at the time, have given evidence to the Safeguarding Board’s review.
Independent Chair of the multi-agency Safeguarding Board, Siân Walker, said:
“It has been almost ten years since concerns were first raised about care at one of Atlas Care’s residential homes. Ten years that the victims, and as time progressed their families, have carried with them knowledge of what happened to them. Ten years too long.
“But in those ten years, a lot has changed, with the passing of new legislation designed to protect vulnerable people from harm, changes in people’s understanding and in the way that care for people with learning disabilities, autism and mental health problems is, or should be, provided.
“This review has sought to identify what happened and why it was able to happen. It has taken first-hand evidence from the families of the victims. And it has gathered intelligence from the commissioning authorities and the Care Quality Commission to reflect on, to see how their practice is different today than it was ten years ago, to ensure that such abuse does not happen again.
“The families of the victims have responded with dignity and with clear determination to have their opinions heard, which is in fact one the themes of our report today – families, those closest to residents who themselves could not communicate effectively, were not only kept apart from seeing their loved ones, but their opinions and their concerns raised at the time about the care that their relatives were receiving were not listened to sufficiently.”
One family member describes what happened as ‘catalogue of horrors’. Others describe not being listened to; that regulation and monitoring of the homes was inadequate at best; and that there was no accountability for what was happening.
“The oversight wasn’t there,” says one family member. Another that there was no credible monitoring or inspection; that inspectors did not seek out families’ experience of visiting; that CQC did not have knowledge of things they should have known.
One describes commissioners as ‘lax’; another that commissioners hadn’t planned very well.
“While they were happy to commission Atlas as the provider, they failed to monitor the quality of the service,” said another.
Families are also deeply critical of the court process that ensued.
Victims were made to feel demonised, one family member reports. They felt that the court process was weighted against them.
‘Ten barristers defending Directors and staff. Our relatives had one,’ says another. ‘Victim blaming was rife’, another.
And, ‘From the families’s perspective, justice has not been realised,’ says one family member in reaction to Director Paul Hewitt’s conviction later becoming quashed and fines set aside.
Back in 2011, residential homes and other appropriate care for people with complex care needs and challenging behaviours were few and far between, meaning that often, residents were placed in homes many miles from their former lives and families.
There was no compunction for placing authorities to inform ‘host’ authorities in the areas that the homes were.
A further claim made by families is that the authorities failed to challenge Atlas Care. Care managers didn’t appear to follow up questionable methods, such as stopping phone calls between residents and their families; they felt that Atlas’s expertise in caring for people with complex care needs was ‘assumed but not evidenced’; that Atlas’s approach, which involved deliberate exclusions of families was not challenged by commissioners, inspectorate, social workers or psychiatrists.
The review identifies six main findings:
- Relationship between host and placing authorities – There needs to be a mandatory notification system to ensure that host local authorities are informed when adults with learning disabilities are placed by other local authorities into residential homes in their areas. That notification should include information about the individuals, and what their care needs are. And the host authorities should have some way of capturing or using that information.
- Analysing risk of harm in organisations – CQC inspections are a measure of care quality, but there needs to be consideration of how local intelligence about care services are shared. For example a repository of ‘intelligence’ about care providers accessible to commissioning bodies should be encouraged; and there should be some shared way to assist analysis of indicators of harm.
- Assessing quality of care in commissioned services – Commissioning authorities must keep responsibility for having oversight of the quality of care delivered, so there needs to be a system for sharing and collating concerns about providers.
- Market sufficiency and risk profile – More must be done to reduce out of area residential placements, by ensuring that there is sufficient supply of appropriate care provision local to where people, and their families, live. There has been progress in this respect, but there remains insufficient local provision for adults with complex support needs and accommodation and support.
- Reviewing how care and support needs are met – Periodic reviews, sometimes once a year, should be replaced with continuing complex case management; and those doing the continuing case management must understand what the aspirations are of the people with learning disabilities, and their families.
- Absence of relationship – In this case, families’ views about how their loved ones were, in those placements, was not actively sought. Their expertise was not recognised. Commissioning authorities should consider testing their procedures to determine how a family could challenge a professional who appeared duped, in this case by Atlas employees.
“With the benefit of hind sight, and with the ability to see the bigger picture, it is clear that there were many things wrong with the mechanisms that we would expect today to ensure that vulnerable people are safe from harm,” said Siân Walker.
“As an independent Chair, I have seen little evidence of properly joined-up working, between commissioning authorities, host authority, CQC, and residents’ families in 2011. There was no compunction for host authorities to be told by other commissioners when new placements from out of county were made into homes in their area. And with a lack of regular monitoring on the ground, it’s easy to understand why families have had the belief that their relatives were placed out of sight and out of mind.
“A lot has changed since then, although more change is needed. As well as new legislation, commissioning authorities have changed the way they work, and work together. There are new ways of working and new ways of responding to risk.
“Authorities in Devon for example do more to support people with learning disabilities to live safely and with support as necessary within their community. And a procedure is being developed in Devon to record people being placed in the county by other local authorities, and for sharing information about care providers with other local authorities that are considering placements.
“All of the commissioning authorities, in this case Bath and North East Somerset; Torbay, West Berkshire; Wiltshire; Royal Borough of Windsor and Maidenhead, have all improved the ways that review individual placements. They all have had contract monitoring systems and processes in place for some years that they did not have at the time of this abuse.
“Most of the authorities have invested in the Mental Capacity Act and Deprivation of Liberty Safeguards training, and many have arrangements in place to strengthen the scrutiny of contracts and to escalate emerging concerns.”
“All the commissioning bodies are making efforts to ‘shape’ the market for care provision, to ensure that there is care available nearer to home, to reduce the likelihood of people being moved away from their areas of origin.
“The Care Quality Commission has also undergone many changes since the end of the Atlas trial, including adopting new policy guidance on registrations and variations to registration for providers that support people specifically with a learning disability and/or autism.”
The review makes six recommendations. The Devon Safeguarding Adult Board should:
- Recommend that the Department of Health, NHS England and the Local Government Association: Incentivise commissioning bodies to engage in commissioning that is appropriate and closer to home; assert a new requirement that stops commissioners placing people in residential services that would not be registered by CQC, or that ‘take anyone’; make it compulsory for commissioners to inform host authorities of prospective placements; make a requirement for specific funding for essential monitoring, reviewing and safeguarding, should that be necessary, and for residents access to local health services.
- Commend the replacement of periodic reviews with continuing, complex case management.
- Incentivise creation of a repository of ‘intelligence’ about providers that is accessible to commissioning bodies.
- Ensure that individual contracts and support plans explicitly protect individuals’ health and wellbeing and keep them from harm.
- Review impact on corporate governance of the care of large numbers of adult residents and the public sponsorship involved.
- Promote the fact that proceedings can be taken under the Company Directors Disqualification Act 1986, when residents are harmed and a company’s inattention to outcomes for them is recurrent.
Siân Walker said: “As the independent Chair of Devon’s Safeguarding Adult Board, I will be informing the appropriate bodies, agencies and lobbying the Government Department of Health and Social Care in respect of our findings in relation to Atlas Care, and I will be making our recommendations to them.
“This Board is committed to seeing to the best of our ability that these recommendations are implemented.
“As well as the families and commissioners, I want to thank Devon and Cornwall Police for their input to the review, and for the significant resources they put in supporting the families throughout their investigations and legal proceedings.
“We remain in conversation with the commissioning bodies identified in this review to ensure that lessons learned are acted upon, and that in this county, the abuse of vulnerable adults does not happen again.
“And we also would like to continue our work with some of the families to inform our own learning about this and future Safeguarding Adult Reviews.”